How to use data, IT systems to address social determinants

To improve health, providers need to better understand the intersection of people, process, and technology.

We are seeing a fundamental shift in healthcare delivery from sick care to whole person care. The increasing emphasis on wellness and the transition from fee-for-service to value-based care is an opportunity to help populations focus on prevention and holistic care.

Moreover, most of a patient’s health journey occurs outside the hospital, with 80 percent of health experiences occurring outside of inpatient settings. With medical care accounting for a small portion of a patient’s health, healthcare providers are being forced to deeply consider and incorporate the social determinants of health in practice, especially when looking at high-impact interventions.

Healthcare professionals are problem solvers—they triage regularly and hope to effectively solve healthcare challenges. How can they be sure they solve the correct ones? Data collected today often reveals key problem areas within the hospital’s continuum of care, but it does not always address the root cause of a health issue.

Consider this brief narrative—a person collapses on a bus and the driver calls an ambulance, which brings them to the hospital emergency department. In this case, key healthcare costs and data points (at a high level) are generated from the ambulance ride, the EMT’s treatment time, the registration process into the hospital system, the clinicians who review the case, the treatment, associated prescriptions and the discharge process out of the hospital.

The data captured by each of these transactions will provide important information, but it might not provide the whole picture, and the root cause of the event might be masked without the additional data markers that the social determinants of health provide.

The visibility and timeliness of information is enabling decision makers to identify key problem areas within the continuum of care and take corrective action to address those areas. Having an interdisciplinary data strategy is key to identifying, and ultimately solving, the right issue.

As such, having strong processes in place will ensure care interventions are effective, capable and reliable. A good process works; a great process drives value. Part of framing that value is aligning problem-solving methodologies with organizational strategy, mission, vision and values. This approach will ensure more organized, sustained efforts that yield better outcomes.

After a healthcare organization identifies the problem, solutions should be anchored in an ideal—system-wide objectives should work in tandem with the strategic direction. If an organization’s mission is to narrow the access gap, it is crucial that this message be embedded in each step of the process.

A solution anchored in the Triple Aim, for example, will make reducing cost, improving quality of care and creating a more coordinated, patient-centric experience a priority. Alignment creates a sense of purpose and enables engagement teams to see beyond their siloed departments.

As organizations evaluate workflows and value streams, it is important to keep this in mind as they work to remove waste, standardize and eliminate variation, reduce errors and, ultimately, improve processes.

To improve, organizations must quantify progress. In a time of innovation, there is increasing opportunity to leverage technology to access and collect meaningful data so that they can measure, track and demonstrate progress.

Electronic health record data that includes more information about the social determinants of health can help discern root causes of health. A holistic data-collection strategy across multiple sources can underscore the significance of predictive analytics.

As organizations leverage different technological tools and platforms, they must define success through health outcomes and community standards. This will translate to addressing that 80 percent—lower crime rates, increased safety for children, decreased substance abuse, higher accessibility to nutritious food sources and more.

Ultimately, the solution lies in understanding the intersection of people, process and technology—where a variety of organizations can leverage data to assess the populations to be targeted, their core issues, ways in which interventions can be most effective and how to initiate action.

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